Primary Care Future Appointment Request Form - For New and Established Patients

Austin Regional Clinic is excited to announce that in the next few weeks our “Make an Appointment” Page
will relaunch with enhanced new and improved functionality making scheduling appointments for you and your
family quicker and easier than before. It’s part of our goal to make your access to coordinated health care
easier and simpler.

New improvements you can expect include:

One form for all appointments – Regardless of what your appointment
need may be, there will be one single form type to request an appointment online.
As always, dial 911 in cases of emergencies.

Response Time Notifications – A notification of response times will be available at time
your appointment is requested.

01/05/15: Due to an increase in Online Appointment requests,
please expect a response to your future appointment request within 4-5 business days. We will continue to respond to
your same-day requests within 2 to 4 hours on regular business days. If you need a response before that time, please call
your doctor's office directly.

Please Let us know your scheduling preference during the week
(you may check more than one)*
MondayTuesdayWednesdayThursdayFriday
If you would like to request a specific date, time, or time frame` (i.e. in two
weeks), please specify in the comments field below.
8:00am-10:00am10:00am-11:45am1:00pm-3:00pm3:00pm-4:45pm

Would you like an e-mail appointment confirmation sent to your mobile phone?
YesNoPlease select No if you do not want to receive a mobile confirmation.This service is currently provided only for the mobile carriers listed in the drop-down list below.
Mobile Phone # (including area code) ()
-
Mobile Phone Carrier:

Change
of Address and/or Phone. Please fill in the following information if you check
this box.

*Street Address:

*City:

*State:

*Zip:

*Primary Phone:

()
-
Ext.

Secondary Phone:

()
-
Ext.

Additional Comments or Insurance Changes (500 characters maximum):

This is a secure site. All personal information is encrypted. Please
be sure to include a daytime phone where you can be contacted if there are any
questions regarding your request. Please remember to bring your insurance card
to the appointment.